Patient Experiences with Pregnancy Planning and Perspectives on Reproductive Care in Community Health Centers: A Qualitative Study of African American Women in Chicago

Social Safety for Black Women in Perinatal Health Care: A Concept Analysis

INTRODUCTION

Non-Hispanic Black women and their infants experience the worst pregnancy-related outcomes in the United States. Social safety is a health-relevant resource found in environments communicating safety, connectedness, inclusion, and protection. Approaches promoting social safety may be particularly relevant to preventing adverse perinatal health outcomes among Black women. However, there remains a lack of conceptual clarity. The purpose of this concept analysis was to provide a theoretical clarification of the concept social safety for Black women within perinatal health care.

METHODS

PubMed, PsycINFO, and CINAHL were searched using Boolean search strategy. Retrieved articles were managed in Zotero. Duplicates were removed, and each article was assessed and categorized by both investigators. Articles reporting Black women's perinatal health care experiences were included. Thematic analysis guided by Rodgers' evolutionary method identified defining attributes, antecedents, and consequences of social safety in perinatal care for Black women.

RESULTS

Social safety for Black women is defined as the process of feeling understood, respected, cared for, and in control in perinatal health care settings that make space, care for, and recognize strengths, thereby cultivating safety and empowerment.

DISCUSSION

Social safety offers actionable insights for practice and research that have the potential to drive positive change in perinatal care delivery for Black women. Developing interventions and measurements that are valid, reliable, and reflect social safety are essential to promote positive experiences and equity in health care practices and policies.

A Scoping Review of Barriers and Facilitators for Preconception Care: Lessons for Global Health Policies and Programs

Preconception care (PCC) encompasses a set of actions taken before pregnancy to support the health and well-being of women before conception to improve maternal and child health (MCH) outcomes. The utilization of PCC services is influenced by multifaceted factors that can either enable or impede women's capacity to access and utilize them effectively. This scoping review examined the barriers and facilitators influencing the utilization of PCC services among women of reproductive age (15-49 years) at both individual and community levels. Through an extensive review of published articles from 2004 to 2021, including peer-reviewed sources, barriers and facilitators were identified. At the individual level, barriers included limited knowledge about PCC, neglect of self-health, and financial constraints. Community-level barriers encompassed insufficient supply of supplements, restricted access to health care, high health care costs, and setbacks due to delayed delivery of MCH services. Conversely, individuals reported that credible sources of information, such as friends, family, and community health volunteers, facilitated their engagement with PCC services. At the community level, facilitators included government-regulated supply chains for supplements and the involvement of community workers in health monitoring. Understanding and addressing these factors can help improve the utilization of PCC services among women of reproductive age (WRA) and improve MCH outcomes.

Discrimination during childbirth and postpartum care utilization among Black birthing people in California, United States

BACKGROUND

The purpose of this study was to investigate the relationship between discrimination during childbirth hospitalization and postpartum care utilization among Black birthing people in California, United States.

METHODS

This was a secondary analysis of data from the Listening to Mothers in California survey, a population-based survey of individuals with a singleton hospital-based birth in California in 2016. The primary outcome was number of postpartum care visits. The primary exposures were racial, language, and insurance discrimination. A multiple linear regression model was used to estimate associations between discrimination and postpartum care use, adjusting for sociodemographic covariates.

RESULTS

Black birthing people in the sample had an average of two postpartum visits. Almost 15% of the sample reported one or more forms of discrimination during hospital-based childbirth. In adjusted models, racial discrimination (β = 0.09, 95% CI = 0.04-0.14, p < 0.01) and language discrimination (β = 1.03, 95% CI = 0.98-1.07, p < 0.01) were associated with increased postpartum visits, while insurance discrimination was linked to decreased postpartum visits (β = -0.96, 95% CI = -1.04 to -0.89, p < 0.01).

CONCLUSION

Among Black birthing people in California, the drivers of postpartum care utilization after childbirth are complex. There are multiple negative drivers (e.g., experiencing racial and language discrimination and unmet needs), barriers (e.g., insurance discrimination), and positive drivers (e.g., clinician type and education) that affect postpartum care utilization among Black birthing people.

Preconception, Interconception, and reproductive health screening tools: A systematic review

OBJECTIVE

To identify and describe the standardized interconception and preconception screening tools for reproductive health needs that are applicable in general outpatient clinical practice.

DATA SOURCES AND STUDY SETTING

This systematic review identifies research on pregnancy intention screening and counseling tools, and standardized approaches to preconception and interconception care. We focus on tools designed for clinical settings, but also include research tools with potential for clinical implementation. These tools may include a component of contraceptive counseling, but those focusing solely on contraceptive counseling were excluded. Data were collected from studies done in the United States between January 2000 and March 2022.

STUDY DESIGN

We performed a systematic literature search to generate a list of unique tools, assessed the quality of evidence supporting each tool, and described the peer-reviewed clinical applications of each. We used the Mixed Methods Appraisal Tool to appraise the quality of individual studies.

DATA COLLECTION/EXTRACTION METHODS

We searched PubMed, Web of Science, and CINAHL databases for standardized preconception and interconception health screening tools published in English from January 2000 through March 2022. We used keywords "preconception care," "interconception care," "family planning," "contraception," "reproductive health services," and "counseling." Utilizing the Preferred Reporting Items for Systematic Reviews guidelines, we screened titles and abstracts to identify studies for full text review.

PRINCIPAL FINDINGS

The search resulted in 15,399 studies. After removing 4172 duplicates, we screened 11,227 titles/abstracts and advanced 207 for full-text review. From these, we identified 53 eligible studies representing 22 tools/standardized approaches, of which 10 had evidence from randomized clinical trials. These ranged widely in design, setting, and population of study.

CONCLUSIONS

Clinicians have a choice of tools when implementing standard reproductive screening services. A growing body of research can inform the selection of an appropriate tool, and more study is needed to establish effects on long-term patient outcomes.

Facilitators of and Barriers to Successful Implementation of the One Key Question® Pregnancy Intention Screening Tool

Background:

One Key Question^® (OKQ) is a tool that embeds a patient-centered screening into routine visits with the goal of making pregnancy intention screening universal, but widespread implementation has not yet been adopted. We aimed to explore the barriers and facilitators of OKQ implementation to better understand how to best implement the tool across different settings.

Methods:

We invited staff and clinicians from one obstetrics and gynecology clinic and one family medicine clinic, which previously implemented OKQ, to complete surveys and qualitative interviews about their experiences with the tool. The interview guide and thematic analysis of the interview transcripts were informed by the Consolidated Framework for Implementation Research (CFIR).

Main Findings:

Major facilitators of OKQ implementation are the simplicity of the tool, engagement of clinic leadership, and compatibility between the perceived goals of the tool and those of practice staff and clinicians. Although participants indicated that OKQ had a minimal impact on clinic workflow during its implementation, preimplementation time concerns were a major barrier to implementation in both clinics. Barriers seen in the family medicine practice included OKQ distracting from the visit agenda, and concerns about the OKQ gold standard protocol of screening each patient at every visit. Participants even suggested asking OKQ only during annual check-up appointments.

Conclusions:

The perceived alignment between the tool's goals and those of clinic stakeholders was an important facilitator of OKQ implementation success. However, characteristics of the clinic setting, such as competing medical priorities and time constraints, influenced initial attitudes toward the feasibility of the intervention. Clinical Trial Registration Number: NCT03947788

Preconception health service provision among women with and without substance use disorders

BACKGROUND

Drug and alcohol use during pregnancy is associated with significant adverse birth outcomes and maternal morbidity. Addressing health and risky behaviors before pregnancy, in the preconception period, can improve both maternal and infant outcomes. However, the prevalence of preconception service delivery among women with substance use disorders (SUD) is unknown.

METHODS

Using Optum®, a de-identified Electronic Health Record dataset containing data from 5 million nationally distributed US adults from 2010 to 2018, we conducted a cross-sectional analysis of 18-55-year-old women with delivery between 2012 and 2018 (n = 52,565). Preconception services received in the year before pregnancy were identified using ICD-9/10 V and Z codes. Logistic regression was used to assess the relationship of any SUD vs. no SUD and preconception services received before and after adjusting for confounding.

RESULTS

Average age was 29.3 ( ± 5.0 years); 6.4% (n = 3371) of the sample had a diagnosis of any SUD and 6.0% (n = 3144) received any preconception services in the year before pregnancy. Women with SUD vs. without had higher prevalence of receiving any preconception services (9.6% versus 5.7%, p < 0.001). Compared to women without SUD, women with SUD had increased odds of receiving preconception services adjusting for medical comorbidities (OR=1.39; 95% CI=1.22-1.58) that was no longer significant when psychiatric comorbidities were added (OR=1.11; 95% CI=0.97-1.27).

CONCLUSIONS

There are numerous missed opportunities to provide preconception services to women with and without SUD. While delivering preconception services, healthcare providers have an opportunity to screen for SUD which may be more prevalent among women with psychiatric and medical problems.

Black-White Differences in Pregnancy Desire During the Transition to Adulthood

This article explores race differences in the desire to avoid pregnancy or become pregnant using survey data from a random sample of 914 young women (ages 18-22) living in a Michigan county and semi-structured interviews with a subsample of 60 of the women. In the survey data, desire for pregnancy, indifference, and ambivalence are very rare but are more prevalent among Black women than White women. In the semi-structured interviews, although few women described fatalistic beliefs or lack of planning for future pregnancies, Black and White women did so equally often. Women more often described fatalistic beliefs and lack of planning when retrospectively describing their past than when prospectively describing their future. Using the survey data to compare prospective desires for a future pregnancy with women's recollections of those desires after they conceived, more Black women shifted positive than shifted negative, and Black women were more likely to shift positive than White women-that is, Black women do not differentially retrospectively overreport prospectively desired pregnancies as having been undesired before conception. Young women's consistent (over repeated interviews) prospective expression of strong desire to avoid pregnancy and correspondingly weak desire for pregnancy, along with the similarity of Black and White women's pregnancy plans, lead us to conclude that a "planning paradigm"-in which young women are encouraged and supported in implementing their pregnancy desires-is probably appropriate for the vast majority of young women and, most importantly, is similarly appropriate for Black and White young women.

Perceived Discriminatory Factors that Impact Prenatal Care Satisfaction and Attendance Among Adolescent and Young Adult Couples

OBJECTIVE

To identify possible discriminatory factors that lead to prenatal care dissatisfaction and disengagement from prenatal care among young, expecting couples with a focus on exploring the experiences of Black and Latinx participants.

METHODS

A total of 296 young adolescent couples were recruited. Each couple consisted of an expecting female (ExpF) and an expecting male (ExpM). Participants were asked to give responses to a survey, and data was collected at 3 different time points.

PARTICIPANTS

The sample consisted of 296 expecting young couples.

SETTING

Participants were recruited from obstetrics and gynecology clinics and ultrasound clinics from 4 university-affiliated hospitals in southern Connecticut.

OUTCOME MEASURES

The main outcome measure was prenatal care satisfaction. The secondary outcome was number of prenatal care visits that were attended by each member of the couple dyad. Both of these outcomes were assessed to evaluate whether discriminatory factors that participants experienced in healthcare had an effect on each outcome.

RESULTS

A total of 51 males (17.5%) and 36 females (12.4%) reported a perception of experiencing discrimination in the healthcare system a few times a year or more. Those who believed that race contributed to discrimination in the healthcare system were 2.45 times more likely to have an unpleasant prenatal visit (P = .018). Those who believed that age contributed to discrimination in the healthcare system were 2.74 times more likely to have an unpleasant prenatal visit (P = .001). Participants who believed that physical appearance contributed to discrimination in the healthcare system were 2.83 times more likely to have an unpleasant prenatal visit (P = .01).

CONCLUSION

Black and Latinx young expecting couples are not exempt from discriminatory experiences during prenatal care. Recommendations for quality improvement in prenatal healthcare settings include implementation of standard evaluative measures specific to personal treatment and supportiveness of the medical team.

Using reproductive life plan-based information in a primary health care center increased Iranian women's knowledge of fertility, but not their future fertility plan: A randomized, controlled trial

OBJECTIVES

Reproductive Life Plan (RLP)-based information in counseling has been reported in the USA and Sweden to increase women's knowledge of fertility and informed decision making about future fertility plans. This study examined if utilizing the RLP tool would have the same impact on Iranian women.

DESIGN

A randomized, three-armed, controlled trial. 181 women were randomly allocated to the intervention group (IG, n = 61), control group 1 (CG1, n = 60) or control group 2 (CG2, n = 60).

SETTING

A primary health care center in the Sari city, the Provincial capital of Mazandaran, Iran.

PARTICIPANTS

Women of reproductive age who were able to conceive.

INTERVENTIONS

The intervention group received oral and written information about fertility based on the RLP tool. Participants were contacted 2 months after the intervention. The primary outcome measure was the change in women's knowledge of fertility, particularly folic acid intake prior to pregnancy, over a 2 month period. The change in women's family planning intentions were also assessed. The participants in the IG shared their experiences at follow-up.

FINDINGS

At baseline, there was no difference between the groups regarding the mean knowledge of fertility score. At 2 months, after adjustment for age, history of pregnancy and baseline values, the between group difference in change from baseline was 5.8 (p < 0.001). While there was no significant difference between the IG and CG1 for folic acid intake prior to pregnancy at baseline, the group difference for folic acid intake prior to pregnancy post intervention was statistically significant (85% vs 25%, p < 0.001). At follow-up, women's desire to have more children, preferred age to conceive the last child and the desired age gap between children in the IG and CG1 did not significantly change over time. Women reported the RLP counseling tool used by midwives as useful.

KEY CONCLUSIONS

Provision of RLP-based information for Iranian women with a clear pregnancy intention in the context of a stable relationship, increased knowledge of fertility without changing their future fertility plan. The RPL counseling tool was appreciated by study participants. The lack of improvement in women's fertility intentions over time may reflect the involvement of other factors influencing decision making about childbearing in Iran. Whether the RLP can change women's behavior is yet to be established.

IMPLICATIONS FOR PRACTICE

The RLP can be used by health care professionals, especially midwives, as a tool to increase women's fertility knowledge, which may result in fertility behavior change.